Ovarian neoplasms.

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Ovarian neoplasms.
Ovarian neoplasms. Anita Chudecka - Glaz
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• Human ovarian neoplasms (especially epithelial
  ovarian cancer) presents a major challenge to
  oncological research , because they are
  frequently diagnosed late and show poor prognosis
  and low survival despite the apparent success of
  chemotherapy in achieving remission with no
  evidence of disease.

Ovarian neoplasms. Anita Chudecka - Glaz
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• Epithelial ovarian cancer is the fourth most
  common cause of death from cancer in women and
  the most lethal of gynaecologic neoplasms.

Epithelial ovarian cancer is the fourth most
common cause of death from cancer in women and
the most lethal of gynaecologic neoplasms.
Ovarian neoplasms. Anita Chudecka - Glaz
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• The most important positive prognostic feature
  continues to be diagnosis at an early stage.
• BUT EARLY STAGE OVARIAN CANCERS DONT PRODUCE
  SYMPTOMS !!!

Ovarian neoplasms. Anita Chudecka - Glaz
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• The incidence of ovarian cancer is relatively
  high in Scandinavian (15/100000) countries ,
  lower in western Europe and North America (
  10/100000 ) and low in Japan (3/100000).

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• Two hypotheses have been proposed to explain the
  biological mechanisms that increase the risk of
  ovarian cancer
• genetics
• gonadotropin hypothesis

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• The involvement of gonadotropins in human ovarian
  carcinoma is backed by a number of
  epidemiological and experimental studies showing
• increase occurrence of disease with exposure to
  high levels of LH , FSH during menopause , after
  ovariectomy or during fertility treatment

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• reduced risk of cancer associated with multiple
  pregnancies, oral contraceptives , breast -
  feeding
• LH and hCG receptors are expressed in 40 of
  epithelial ovarian cancer
• LHRH receptors are expressed in almost 80 of EOC

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• deficit of cases of ovarian cancer among women
  with diagnosis of alcoholism in
• animals ovarian cancer may be induced by gonadal
  radiation or chemical toxins that cause premature
  oocyte death , but hypophysectomized animals do
  not develop ovarian tumours after oocyte
  depletion which suggests a specific role of
  gonadotropins

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• other risk factors
• diet
• talc
• pelvic irradiation
• viruses
• age

Ovarian neoplasms. Anita Chudecka - Glaz
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ETIOLOGY

• other risk factors
• PID
• endometriosis
• blood group
• legal status
• education

Ovarian neoplasms. Anita Chudecka - Glaz
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SYMPTOMS

• EOC oftenest are asymptomatic until advanced
  stage , when the prognosis is poor and 5 year
  survival less then 40.

EOC oftenest are asymptomatic until advanced
stage , when the prognosis is poor and 5 year
survival less then 40.
Ovarian neoplasms. Anita Chudecka - Glaz
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SYMPTOMS

• Irrespective of histology , most ovarian
  neoplasms when they have large size in advanced
  stage cause symptoms by exerting pressure on
  contiguous structures (urinary frequency, pelvic
  discomfort and constipation).

Ovarian neoplasms. Anita Chudecka - Glaz
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SYMPTOMS

• The most common
• abdominal swelling
• fatigue
• abdominal pain

Ovarian neoplasms. Anita Chudecka - Glaz
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SYMPTOMS

• Upper abdominal metastases or ascites cause
  nausea, heart burn , bloating , weight loss and
  anorexia.
• Acute abdominal pain secondary to haemorrhage ,
  rupture or torsion can all result from tumour
  growth.

Ovarian neoplasms. Anita Chudecka - Glaz
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SYMPTOMS

• Biologically active hormones , including
  estrogen, progesterone, testosterone ,
  corticosteroids and hCG can be produce by a
  variety of ovarian neoplasms and cause the
  predicted symptoms associated with each compound.

Ovarian neoplasms. Anita Chudecka - Glaz
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DIAGNOSIS

• 1. Physical examination-bimanual rectovaginal
  pelvic examination
• 2. Ultrasound investigation
• 3. Tumour markers
• 4. Ascites puncture
• 5. Biopsy the tumour
• 6. Laparoscopy
• 7. CT
• 8. NMR
• 9. Chest X ray

Ovarian neoplasms. Anita Chudecka - Glaz
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ULTRASONOGRAPHY
ULTRASONOGRAPHY

• abdominal
• transvaginal TVS
• colour Doppler CDI

Ovarian neoplasms. Anita Chudecka - Glaz
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TUMOR MARKERS
CA 125 CA 19-9 CEA

• epithelial ovarian cancer

Ovarian neoplasms. Anita Chudecka - Glaz
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TUMOR MARKERS
AFP

• endodermal sinus tumors
• embryonal carcinomas
• mixed germ cell tumors
• rarely immature teratoma and polyembryoma

Ovarian neoplasms. Anita Chudecka - Glaz
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TUMOR MARKERS
hCG

• chorioncarcinoma
• embryonal carcinoma
• mixed germ cell tumors
• polyembryoma

Ovarian neoplasms. Anita Chudecka - Glaz
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TUMOR MARKERS
ESTRADIOL

• adult granulosa cell tumors
• thecomas

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TUMOR MARKERS
INHIBIN

• adult granulosa cell tumors

Ovarian neoplasms. Anita Chudecka - Glaz
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PREMENOPAUSAL OVARIAN MASS
EXCLUDE NON-GYNAECOLOGICAL PROBLEM
Solid or complex on US OR gt 6
cm OR Elevated AFP/hCG/LDH OR Elevated CA 125
Simple on US AND lt 6 cm AND Normal CA 125
Observation for 6-8 weeks and Gonadotrpopin
suppression
Surgical evaluation
Peristent on US
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POSTMENOPAUSAL OVARIAN MASS
EXCLUDE NON-GYNAECOLOGICAL PROBLEM
Symptomatic OR Complex on US OR gt 3
cm OR Elevated CA 125
Asymptomatic AND Simple on US AND lt 3
cm AND Normal CA 125
Observe with Follow up US
Surgical Evaluation
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DIFFERENTIAL DIAGNOSIS

• gynaecologic
• tuboovarian abscess
• ectopic pregnancy
• leiomyoma
• fallopian tube neoplasia
• luteal or follicular cysts

Ovarian neoplasms. Anita Chudecka - Glaz
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DIFFERENTIAL DIAGNOSIS

• gynaecologic
• ovarian hyperthecosis
• pregnancy luteoma
• theca-lutein cysts
• endometrioma
• simple cysts

Ovarian neoplasms. Anita Chudecka - Glaz
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DIFFERENTIAL DIAGNOSIS

• nongynaecologic
• diverticular disease
• appendiceal abscess
• Crohns disease
• primary nongynaecological malignancy
• pelvic kidney

Ovarian neoplasms. Anita Chudecka - Glaz
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CLASSIFICATION

• 1. Epithelial ovarian tumours - 70 of all
  ovarian neoplasms
• 2. Sex cord stromal tumours 5-10
• 3. Germ cell tumours 15-20
• 4. Metastatic 5
• 5. Other

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SEX CORD STROMAL TUMOURS

• 1. Granulosa stromal cell
• granulosa cell
• thecoma-fibroma
• 2. Sertoli stromal cell
• 3. Lipid cell tumours
• 4. Gynanandroblastoma

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GERM CELL TUMOURS

• 1. Dysgerminoma
• 2. Endodermal sinus tumour
• 3. Embryonal carcinoma
• 4. Polyembryoma
• 5. Chorioncarcinoma
• 6. Teratomas
• 7. Mixed forms
• 8. Gonadoblastoma

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STAGE I

• Growth limited to the ovaries

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STAGE II

• Growth involving one or both ovaries with pelvic
  extension

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STAGE III

• Tumour involving one or both ovaries with
  peritoneal implants outside the pelvis and/or
  positive retroperotoneal or inguinal nodes
  superficial liver metastasis tumour is limited
  to the true pelvis but with histologically proven
  malignant extension to small bowel or omentum

Ovarian neoplasms. Anita Chudecka - Glaz
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STAGE IV

• Tumour involving one or both ovaries with distant
  metastases if pleural effusion is present ,
  there must be positive cytology to allot a case
  to stage IV

Ovarian neoplasms. Anita Chudecka - Glaz
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Five - year survival rates for epithelial ovarian
cancer

• Stage
• IA 82,3
• IB 74,9
• IC 67,7
• IIA 60,6
• IIBIIC 53,8
• III 22,7
• IV 8

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PREDICTORS OF SURVIVAL

• stage
• grade
• age
• residual disease
• max. cytoreductive surgery
• histopathology
• others ( protein p53, CA 125, EGF-R)

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TREATMENT

• surgical
• chemotherapy
• radiotherapy
• hormonal treatment

postoperative procedures
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SURGICAL TREATMENT

• cytoreductive operation
• hysterectomy
• bilateral oophorectomy
• omentectomy
• appendectomy
• lypmphadenectomy ??

Nowotwory jajnika. Anita Chudecka - Glaz
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CHEMOTHERAPY

• CT
• PC
• PAC
• Vepesid or
• Ifosfamid with CDDP as II LINE CHT.
• Hycamptin or Gemzar as III LINE CHT.

I LINE CHEMOTHERAPY
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SURGICAL TREATMENT - EOC

• benign
• In young women conservative surgery usually
  including cystectomy or oophorectomy. In
  postmenopausal women TAH/BSO should be considered
  to avoid the risk of cancer in the future.
• borderline
• In young women conservative surgery oophorectomy
  or USO can be performed. In women who have
  completed their child bearing a
  TAH/BSO/Omentectomy is appropriate always with
  very precise surgical staging.

Ovarian neoplasms. Anita Chudecka - Glaz
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SURGICAL TREATMENT - EOC

• malignant
• In all cases we have to carry out cytoreductive
  surgery. It includes TAH/BSO complete omentectomy
  with resection of any metastatic lesions. In some
  cases bowel resection and retroperitoneal
  lymphadenectomy are necessary in order to obtain
  optimum cytoreduction. Optimum cytoreduction is
  achieved when the largest residual tumour mass
  measures less then 1,5 cm.

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POSTOPERATIVE TREATMENT - EOC

• chemotherapy
• Platinum-based combination with paclitaxel
  chemotherapy is now the standard postoperative
  treatment for patient with ovarian cancer
• radiation therapy
• It is useful method especially in patient who
  have positive second-look laparoscopy or
  laparotomy after chemotherapy treatment but the
  residual mass are less than 2 cm.
• hormonal treatment

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FOLLOW - UP

• second-look laparoscopy every year during first
  5 year to detect early microscopic relapse
• CA 125 every 3 to 4 month
• complete medical history
• physical examination
• rectovaginal pelvic examination

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SCREENING

• Screening is recommended in women with HOCS and
  HBOCS and include
• rectovaginal pelvic examination
• CA 125 determination
• TVS
• prophylactic TAH/BSO

Ovarian neoplasms. Anita Chudecka - Glaz
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MALIGNANT GERM CELL TUMOURS

• Dysgerminoma most common germ cell malignancy ,
  in 10-15 is bilateral , survival rate for early
  stage is 95 and even in advanced stage grater
  then 80 when appropriate adjuvant therapy is
  given. LDH is useful tumour marker. hCG levels is
  elevated in small number of patients. In young
  women and stage I unilateral oophorectomy is
  recommended with inspection and biopsy of
  opposite ovary and staging with retroperitoneal
  lymphadenectomy. In other women TAH/BSO.
  Adjuvant therapy should be given in all patients
  radiotherapy and/or chemotherpy.

Ovarian neoplasms. Anita Chudecka - Glaz
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MALIGNANT GERM CELL TUMOUR

• Embryonal carcinoma is quite rare , rarely
  bilateral and trends to spread intraperitoneally
  , survival is slightly better then with EST
  using the same platinum based chemotherapy
  regiments . Both AFP and hCG can serve as tumour
  markers. Surgical treatment depend on age and
  stage . Adjuvant therapy ( chemotherapy) is
  recommended in all cases.

Ovarian neoplasms. Anita Chudecka - Glaz
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MALIGNANT GERM CELL TUMOURS

• Immature teratoma represents approximately 20 of
  all malignant germ cell tumours and 25 in girls
  under 10. After grade surgicopathologic stage is
  the most prognostic factors. Fortunately most
  patient are diagnosed with early stage.
  Occasionally immature carcinoma produce AFP as
  tumour marker but hCG is never produced. Surgical
  treatment depend on age and stage. Chemotherapy
  is kind of adjuvant therapy but only in immature
  teratoma of all malignant germ cell tumours
  chemotherapy in stage IA grade I does not
  benefit.

Ovarian neoplasms. Anita Chudecka - Glaz
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MALIGNANT GERM CELL TUMOURS

• Endodermal sinus tumour also known as yolk sac
  tumour is an extremely aggressive malignancy.
  Almost never is bilateral. Intraperitoneal and
  hematogenous spread is common. Commonly patients
  present with acute abdomen secondary to
  spontaneous rupture and haemorrhagiae. Platinum
  based chemotherapy significantly improves the
  survival. AFP is useful tumour marker.

Ovarian neoplasms. Anita Chudecka - Glaz
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MALIGNANT GERM CELL TUMOURS

• Chorioncarcinoma nongestational is extremely rare
  , 50 is diagnosed in prepuberatal females ,
  produced hCG as tumour marker . Although
  gestsational chorioncarcinoma is treated
  successfully in most patients with platinum based
  chemotherapy , remission is less common in
  patients with nongestational type.
• Polyembryoma
• Mixed

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BENIGN GERM CELL TUMOURS

• Gonadoblastoma is almost always found in
  patients with gonadal dysgenesis associated with
  chromosome Y. In 50 coexist with malignant germ
  cell tumours
• Teratomas 25-40 of all ovarian neoplasms. The
  most common is cystic teratoma - dermoid cysts.
  Most cases diagnosed in premenopausal women .
  Most patients are asymptomatic and often dermoids
  are diagnosed by usg. This tumours can be
  bilateral in 15. The risk of malignancy is 1-2
  and most commonly occurs in postmenopausal women.
• Struma ovarii it is dermoid where thyroid tissue
  comprises greater than 50 of teratomas. This is
  unusual and accounts for only 2,7 of ovarian
  teratomas.

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SEX CORD STROMAL TUMOURS

• Adult granulosa cell tumours (GCTs) excess
  estrogen production is often found causing
  precocious puberty and menometrorrhagia in
  menstruating or postmenopausal. Endometrial
  hyperplasia or carcinoma is at 60 in patients
  with this tumour.50 occur in postmenopausal
  women and only 5 in prepubertal girls. It is
  interestin that this king of tumour may relapse
  after many years ( even above 20 ) after primary
  diagnosis. Estardiol and in nowadays inhibin are
  useful tumour marker.

Ovarian neoplasms. Anita Chudecka - Glaz
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SEX CORD STROMAL TUMOURS

• Juvenile granulosa cell tumours in 50 occur in
  prebubertal girls , rare relapse after many
  years from diagnosis , typically is early
  recurrence. Rarely lethal as GCTs.
• Fibroma unilateral , diagnosed in 5 decade of
  life. Hormone production is unusual , eventually
  estrogen. It is benign tumour, when 1 to 3
  mitoses are present is called cellular fibroma,
  if greater then 3 it is considered as
  fibrosarcoma.
• Thecoma very similar to fibroma but more commonly
  produce etsrogen which causes postmenopausal
  bleeding , menorrhagia, endometrial hyperplasia
  or cancer.

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SEX CORD STROMAL TUMOURS

• Sertoli stromal cell tumours 1 of all ovarian
  neoplasms , many of these tumours androgen
  producing , many are hormonally inert and some
  occasionally may produce estrogen. Diagnosed of
  pure Sertoli tumours is unlikely in the presence
  of virilization. Rarely is malignant.
• Sertoli-Leydig cell tumours are the most common
  in these group , 40 have evidence of estrogen or
  androgen production, unilateral and occur in 3
  decade of life. Rather frequently is malignant.
• Sex cord tumour with annular tubules (SCTAT) in
  30 associated with Peutz-Jegers syndrome.

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SEX CORD STROMAL TUMOURS

• Lipid cell tumour are typically virilizing with
  increased serum levels of testosteron and
  androstendione. Occasionally produce estrogen,
  estron and cortisol and in 10 cases Cushing
  Syndrom in found. In 20 develop metastases.
• Gynanroblastoma is rare ovarian tumours which
  contain granulosa stromal cell and Sertoli
  stromal cell tumours.
• Leydig cell tumours mean age is 50 and almost
  always behaves in benign fashion. Testosterone is
  commonly produced resulting in mild virilization.

Ovarian neoplasms. Anita Chudecka - Glaz